ABSTRACT
BACKGROUND AND OBJECTIVES: Chronic pain afects thou-sands of people, changing their functionality and emotional status. he Brief Pain Inventory has not been used in populational studies and may be a relevant tool. his study aimed at characterizing chronic pain sensory aspects and their inluence on daily life activities.
METHODS:his is a cross-sectional populational study carried out in a Family Health Unit (Salvador/BA/Brazil). Participated in the study 191 individuals aged 20 years or above, with pain for six months or longer. Brief Pain Inventory was used as eva-luation tool because it has sensory aspects as predicting variables and reactive aspects as outcome variables. Chi-square test was used for proportional analysis and Spearman correlation test was used for intergroup comparisons.
RESULTS: Sample was made up of 86.4% females, single (48.7%), non white (49.7%), low education (46.6%) and low socio-economic level (100.0%). Most participants (46.8%) have reported pain for at least ive years, with predominance of knees (46.1%) and lumbar spine (42.4%), being that 77.5% of the population made systematic use of some painkiller. here has been negative correlation between sensory and reactive va-riables: general activities (p<0.001; r=0.482), mood (p<0.001; r=0.396), walking ability (p<0.001; r=0.318) and working abi-lity (p<0.001; r=0.389). here has been no correlation for the ability of enjoying life (p=0.403; r=0.061).
CONCLUSION:In a low socio-economic level population, chro-nic pain primarily afects knees and lumbar spine with negative in-terference on general activities, mood, walking and working ability.
Keywords:Chronic pain, Epidemiology, Population.
Pain assessment through the brief pain inventory in a low
socio-economic level population*
Caracterização da dor através do inventário breve de dor em população de baixo nível
socioeconômico
Gabriel Venas Santos1, Ana Shirley Maranhão Vieira1, Bruno Teixeira Goes1, Renata de Sousa Mota1, Abrahão Fontes Baptista2,
Kátia Nunes Sá1
*Received the Bahia School of Medicine and Public Health, Salvador, Brazil.
1. Escola Bahiana de Medicina e Saúde Publica, Salvador, BA, Brasil. 2. Universidade Federal da Bahia, Salvador, BA, Brasil.
Submitted in March 29, 2015. Accepted for publication in July 17, 2015.
Conlict of interests: none – Sponsoring sources: none.
Correspondence to: Gabriel Venas Santos
Av. Dom João VI, nº 275 – Brotas 40290-000 Salvador, BA, Brasil. E-mail: renatasmota@gmail.com
© Sociedade Brasileira para o Estudo da Dor
RESUMO
JUSTIFICATIVA E OBJETIVOS: A dor crônica afeta milha-res de pessoas, mudando sua funcionalidade e estado emocional. O Inventário Breve de Dor não tem sido utilizado em estudos populacionais e pode representar uma ferramenta relevante. O objetivo deste estudo foi caracterizar aspectos sensoriais da dor crônica e sua inluência nas atividades diárias.
MÉTODOS: Estudo transversal populacional realizado em Uni-dade de Saúde da Família (Salvador/BA/Brasil). Foram incluídos 191 indivíduos com idade entre 20 anos ou mais, com queixa de dor por um período igual ou superior a seis meses. O Inventário Breve de Dor foi utilizado como um instrumento de avaliação que tem os aspectos sensoriais como variáveis previsoras, e os aspectos reativos como variáveis de desfecho. Foi utilizado o teste qui-quadrado para análise proporcional e correlação de Spear-man para a comparação intergrupo.
RESULTADOS: A amostra foi composta por 86,4% de mulhe-res, solteiros (48,7%), não brancos (49,7%), baixa escolarida-de (46,6%) e baixo nível socioeconômico (100,0%). A maio-ria (46,8%) descreveu dor por período no mínimo de cinco anos, com predominância em joelhos (46,1%) e coluna lombar (42,4%). Setenta e sete e meio por cento da população faz uso sistemático de algum fármaco para dor. Encontrou-se correlação negativa entre as variáveis sensoriais com variáveis reativas: ati-vidades gerais (p<0,001; r=0,482), humor (p<0,001; r=0,396), capacidade de caminhar (p<0,001; r=0,318) e capacidade de tra-balho (p<0,001; r=0,389). Não houve correlação para a capaci-dade de apreciar a vida (p=0,403; r=0,061).
CONCLUSÃO: Em uma população de baixo nível socioeconô-mico, a dor crônica afeta especialmente os joelhos e a coluna lombar com interferência negativa nas atividades gerais, humor, capacidade de andar e trabalhar.
Descritores: Dor crônica,Epidemiologia, População.
INTRODUCTION
Pain is an issue that afects thousands of people worldwide, alte-ring functionality and emotional state. his is one of the biggest health problems today, due to the extreme human sufering it generates1. According to the International Association for the
Study of Pain in 19942, it could be deined as an unpleasant
sensory experience associated with actual or potential damage or described in such terms. Due to its subjective nature, various factors such as problems of cultural psychology, socioecono-mic, and educational policy can inluence pain symptoms and may alleviate or worsen it3. Against this background, many of
the individuals afected by chronic pain, especially from low so-cioeconomic status, have under-diagnosis and under-reporting, and they believe to be normal to experience pain every day. he under-diagnosis causes several problems to health systems. In addition, low socioeconomic and educational levels have been discussed in the literature as factors predisposing to the develop-ment of chronic pain on the individual, relating as a risk factor4.
herefore, pain assessment in communities is very important for a valid notiication issue5.
Several instruments to assess the magnitude and impact of pain-ful experience have been drawn up and are important for scre-ening in healthcare facilities and for the monitoring of people with chronic pain undergoing diferent intervention tools5,6. he
intensity, duration and frequency of pain can seriously impair quality of life or disable people for diferent activities of dai-ly living7. When pain is persistent it can progress to a chronic
state and ceases to represent a symptom to become morbidity8.
Chronic pain reaches endemic levels in the general population and more speciic information about the painful proile can help direct investments to control9. In Brazil, about 13.6 million
in-dividuals sufer due to pain conditions that are characterized as persistent10. In Salvador, approximately 41.4% of the population
are carriers of chronic pain11.
he Brief Pain Inventory (BPI) is a validated instrument in Por-tuguese (Brazil), with psychometric properties that ensure assess the intensity and location of the impact on quality of life, the pain itself and intervention12. It is a means for easy application
and speed of execution that can be self applied or have the help of an interviewer13. his instrument was prepared in 198314 at
the University of Wisconsin, USA, with the fundamental pur-pose of research. Initially developed to evaluate pain related to cancer, BPI was proving to be a suitable measure to assess pain caused by a wide range of clinical conditions is also validated for people with pain not due to cancer15. Reliability coeicients for
BPI scales from non-cancer pain patient data will be comparable to coeicients reported in the literature for cancer patients, and suicient for analysis (0.70 or higher)14. his instrument has not
been applied in low socio economics status population, however, it is presented as a useful tool to detail aspects besides pain inten-sity, location and duration.
Numerous approaches have explored the fundamental dimen-sions of BPI. his instrument was designed to capture two di-mensions of pain: severity and interference, which aimed to in-vestigate two components: pain intensity more broadly, assessing their variability during the day and interference with vital life aspects of the individual12. he application of BPI in
population--based studies can help meet clinical characteristics for the design of the painful cross proile studies and the monitoring of peo-ple with chronic pain who are undergoing interventions from diferent therapeutic modalities such as drugs, physical therapy, programs health education, acupuncture and other procedures16.
his monitoring can help improve health systems and exact po-licies for its control.
he objective of this study was characterize sensory aspects of chronic pain and its inluence on daily activities in a community with low socioeconomic status enrolled at a Family Health Unit in a Health District of the city of Salvador, Bahia, Brazil.
METHODS
his is a descriptive cross-sectional study, conducted at Fami-ly Health Unit (FHU) Zulmira Barros, Salvador, Bahia, Brazil. Municipal Health Salvador is administratively divided into 12 regions called health districts. he multidisciplinary team that operates this unit, which belongs to the area covered by the Sa-nitary District of Boca do Rio, serves the communities of low socioeconomic status RecantoFeliz and Paraiso Azul, located in the Costa Azul neighborhood. Comprises a population of 2,357 inhabitants, according to the Information System Basic Care in 2011. Patients in the community were selected from the clinical records of the oice of the FHU.
Subjects with chronic pain recorded in this the FHU were inclu-ded, aged 20 or older, with intervals of pain equal to or greater than six months and excluded individuals with cognitive inabili-ty to respond to the questions and pregnant women.
After applying the criteria for inclusion and exclusion, the popu-lation was lowered to 1,550 people. Considering a prevalence of 41.4% of chronic pain in Salvador11, patients in that
communi-ty were valued at 620 individuals. Calculating the sample from WINPEPI (freeware package of statistical calculation programs for epidemiologist), with a conidence interval (CI) of 95% and an acceptable diference (absolute accuracy of the estimate) of 7%, we proposed this study with 191 individuals.
For the classiication of socioeconomic status was adopted Eco-nomic Classiication Criterion of Brazil by the Brazilian Associa-tion of PopulaAssocia-tion Studies, 2008, which is an instrument of eco-nomic segmentation that uses the household survey population characteristics to diferentiate and classify it in A1, A2 and B1 (high), B2 and C1 (middle) and C2, D and E (low).
Regarding the distribution of smoking nonsmokers, former smokers and current smokers were used. As with alcoholism, daily consumption or presence of states of intoxication was clas-siied as excessive consumption; random use of a weekly episode and no drunkenness, as moderate consumption; the others were classiied as non-consumers.
Brief Pain Inventory in a reduced form (Short Form), validated for the Portuguese (Brazilian), for use in scientiic research in a “Non-funded academic research” and described as a study of the “Descriptive study or survey”. All steps of the protocol for use of the inventory have been complied with and the Brief Pain Inventory PDF ile was received via email.
he study shows how sensory aspects predictor variables, mean pain intensity in the last 24 hours and the worst pain experien-ced in the last 24 hours, as outcome variables and reactive as-pects, general activity, mood, walking ability, work, relations with other people, sleep and ability to enjoy life. Categorical descriptive data are presented in frequency tables and the num-ber of standard deviation/interrogative range. A Chi-square test for analysis of proportions and Spearman correlation for the comparison between domains (sensory and reactive) of BPI was used. Data were set out and analyzed using SPSS version 17.0 for Windows.
his study was approved by the Escola Bahiana de Medicina e Saúde Pública (EBMSP) (protocol number 079/2011 and au-thorized by the Municipal Health Department of the city of Sal-vador/Bahia (letter number 233/2011). All participants signed the Free and Informed Consent Term (FICT).
RESULTS
he sample consisted of 191 subjects, 165 (86.4%) were fema-le, most consisting of single (48.7%), designated as non-white by self-report (49.7%), low education (46.6%) and low income (100.0%). he most consisted of nonsmokers (60.7%) and those who did not consumption of alcoholic (59.7%). Many of the individuals (46.8%) reported pain in the last ive years (Table 1). he mean age was 46.2±13.8 years and the most of the sample was concentrated in the stratum 31-59 years. Overweight and obesity grade I prevailed among participants, present in 88 subjects (56%). For the characterization of pain through the BPI, the results were shown in the order identiied in the inventory. he irst item (Preliminary Screening), against questioning «In life, some pe-ople have pain from time to time (headache and toothache for exemple). You had today, these diferent pain?», 49.2% of the population was told that on the questionnaire felt headache and toothache.
In the graphical representation of the body map described in BPI, in order to identify the locations afected by pain, gave greater presence of knee pain (46.1%), back pain (42.4%) and headache (35.5%); and less involvement of the cervical region (17.7%), forearms (17.1%), hands (14.1%) and chest (4.7%). To verify the association of spinal pain with knee pain, it was found that 38 (19%) patients reported the presence of involve-ment of both regions simultaneously.
To characterize aspects of intensity and interference, tables 2 and 3 express respectively, the description of sensory and reactive variables. Much of the sample reported using pharmacological treatment as a better measure for pain relief and 77.5% of the population makes use of some pain medication, and within this population, 59.5% to 1 makes use of medication 26 4% to 2% and 14.2 drugs to 3. he most of individuals (46.1%) makes regular use
of analgesics, anti-inlammatories 30 (15.7%) and 27 (14 1%) of both drugs. Faced with this, the sample interviewed reported that the improvement caused by treatments or medications used provided complete relief in 68 individuals (35.8%), 14 subjects (7.4%) reported 50% relief and 17 (8.9%) got no relief against use of drugs or treatments.
Table 1. Socio-demographic characterization of the sample, a po-pulation of low socioeconomic status is enrolled in a health facility, Salvador, Bahia, Brazil
Variables n %
Gender Female
Male
165 26
86.4 13.6
Age (years) 18 to 30 23 12.0
31 to 60 144 75.4
61 to 90 24 12.6
Marital state Single 93 48.7
Married 71 37.2
Others 27 14.1
Skin color Non white 178 93.2
White 13 6.8
Smokers No 115 60.5
Yes 29 15.3
Formersmokers 46 24.2
Consumption of alcoholic Non-consumer 114 59.7
Moderate 72 37.7
Excessive 5 2.6
Time categorized pain Lessthan 5 years 89 46.8
Between 5 and 10 years 59 31.1
Longerthan 10 years 42 22.1
Table 2. Characterization of the sensory (intensity) aspects of pain through the Brief Pain Inventory
Intensity (Last 24 hours)a x~(IIQ)
Worst pain 8.0 (5.0-10.0)
Least pain 3.0 (2.0-5.0)
Average pain 6.0 (4.0-8.0)
Pain now 2.0 (0.0-0.5)
a = numerical scale of variation of 0-10, where 0 is no pain and 10 the worst possible pain.
Table 3. Characterization of the reactive (interference) aspects of pain through the Brief Pain Inventory
Interference (Last 24 hours)a x~(IIQ)
General activity 7.0 (2.0-10.0)
Humor 7.0 (2.0-10.0)
Walkability 5.0 (0.0-9.0)
Workability 7.0 (0.0-10.0)
Relationships with other people 1.5 (0.0-8.0)
Sleep 5.0 (0.0-10.0)
Ability to appreciate life 0.0 (0.0-7.0)
Analyzing the correlation between sensory variables (mean pain felt in the last 24 hours and worst pain experienced in the last 24 hours) and reactive variables, there was moderate to signiicant weak cor-relations with the exception of variables felt worse pain and average pain interference with the ability to enjoy life (Table 4).
Table 4. Correlation between sensory and reactive variables using the Brief Pain Inventory in a low socioeconomic level population
Intensity of the worst pain a
Intensity of the mean pain a
R p R p value
Pain interference in ge-neral activity b
0.482 <0.001 0.261 <0.001
Pain interference in hu-mor b
0.396 <0.001 0.205 0.004
Pain interference in walk ability b
0.318 <0.001 0.284 <0.001
Pain interference in work ability b
0.389 <0.001 0.283 <0.001
Pain interference in re-lationships with other people b
0.236 <0.001 0.285 <0.001
Pain interference in sleep b
0.239 <0.001 0.198 <0.001
Pain interference in abil-ity to appreciate life b
0.061 0.403 0.168 0.021
a = scale of variation of 0-10, where 0 is no pain and 10 the worst possible pain. b = scale of variation of 0-10, where 0 does not interfere and 10 is complete interference.
DISCUSSION
Chronic pain is widely recognized as a major public health pro-blem with signiicant physical, psychological and relationship with major socioeconomic consequences. his study sought to characterize the pain proile through BPI in a community with low socioeconomic status, demonstrating that the instrument used is presented as a comprehensive tool for this population le-vel and presented correlations between the diferent sensory and reactive in the presence of chronic pain issues.
As the Brief Questionnaire has never been applied at the popu-lation level, especially in popupopu-lations with low socioeconomic status, we might suppose that this would not be an appropriate instrument to assess pain in this population level. However, the sample demonstrated ease of understanding and knowledge. he demographic proile of people who sufer from chronic pain in this population is similar to that observed in population studies17-19.
Women, unmarried, non-alcoholic, non-smokers, middle age, low education level deined by self-report are the most afected by chro-nic pain. High presence of class I obesity in our sample, which has also been conirmed by various studies showing that high body mass index is associated with chronic pain in population studies19 was
observed and can be relationed with local body afected.
Sites that had been more afected by sore were knees, back and head in the present sample. he lumbar region has been regarded
as the most afected place in several population bases studies20,24.
However, also the presence of high levels of pain in the knees in the population of Salvador22 have been observed and is believed
to excess body weight have a relationship between mechanic low back pain and pain in the knees, and, in the case of a population with low socioeconomic status, the displacement and walk in a geographically disadvantaged housing conditions, irregular ac-cesses, can contribute to the present in the sample studied com-plaint18. Headache is also often described as a pain that afects
many people of the world population23. It is possible that high
levels of physical and emotional stress can justify the most afec-ted sites in populations of low socioeconomic status.
Although safe and efective, non-pharmacological therapies are not widely used by individuals with chronic pain. Much of the population is presented as treatments and measures to control pain exclusive use of pharmacological therapy, with high con-sumption of analgesics. One of the main reasons for using self--medication is the presence of chronic pain24-25. In countries like
the United States and England, the major use of these drugs has largely concerned professionals and health managers, it is an indication that the population is increasingly sufering with chronic pain26. Likely that the indiscriminate use of analgesics
and anti-inlammatory, associated with the belief that pain is a normal phenomenon, are the genesis of this disease. Public heal-th measures involving education programs for heal-the population is made to inform suferers of chronic pain on the risks of chronic use of analgesics and mechanisms perpetuating the problem25.
BPI has advantages over other instruments to be a feature of mul-tidimensional evaluation that can assess the severity of pain at the time and in the past, afected sites and still the main reactive aspects that afect the quality of life of individuals. hrough the impact on the general activity, mood, work, sleep, interpersonal relationships and ability to walk and enjoy life, this tool can encompass the main aspects involved with chronic pain27. he present study
de-monstrated that BPI can be successfully applied in population studies. Pain intensity in the population measure both the pain worse, lesser pain, average pain, and pain at the time of evaluation show consistent data conirming the ease of understanding of this population regarding the instrument used by a population of low education and socioeconomic, may enable strategies for reducing pain in this population, as has been stated in some studies28.
In the present sample was observed that the most afected aspect was to perform general activities, followed by impacts on mood, ability to walk and work. Relationships and the ability to enjoy life aspects were the least afected, conirmed by the description of a general health rated as good by this population. Studies cor-roborate the results in these dimensions39-32. Less signiicant
cor-relations were also observed between increased pain severity and relationship with other people, sleep quality, and especially the ability to enjoy life.
phenomena are involved in the secondary in the presence of chro-nic diseases gains and generate high costs for all segments involved with the biopsychosocial status of individuals with chronic pain35.
Humor can be understood as a standard or complex state of di-ferent behaviors, thoughts and bodily expressions that change according to life events and meanings attributed to these36. he
pain impacts quality of life as well as in reducing work-related skills, as already described, mood and pleasure being able to cause emotional changes afecting individuals in the motivational and afective cognitive behavioral aspects inluencing exaggeratedly the experience and intensity of pain37. A few studies have reported
sig-niicant results compared to declines of some disorders or mood depending on the pain, usually are related cases of chronic pain. he behavioral and cognitive characteristics in the sample can generate little inluence on the negative perception of life due to the presence of chronic pain. his may conirm that the lives of individuals with chronic pain can be severely compromised in diferent measurable aspects such as the intensity of chronic pain, although it is an important marker for assessing the im-pacts on the quality of life of individuals, it is not enough to understand the multidimensional aspects that afect the quality of life of individuals sufering from chronic pain38.
he present study has major limitations as the sample heterogenei-ty with respect to time of pain, the inherent problem of the instru-ment on the basis of recalling information and the lack of a com-parison group without chronic pain. hese limitations may have inluenced the expression of the correlation coeicients. Being probably one of the irst population-based studies that applied the BPI for describing chronic pain, this study demonstrated good ability to use that tool in population studies, with conditions to correlate sensory and reactive variables. Future population-based studies, even in a population of low socioeconomic and educatio-nal level, can beneit from the use of BPI as useful and appropriate to measure diferent dimensions related to chronic pain tool.
CONCLUSION
In summary, the present study it was observed that in a popula-tion of low socioeconomic status, chronic pain afects mainly the regions of the knee and the lumbar spine and increasing the inten-sity of chronic pain was negatively correlated to the performance of general activities impacted in mood, ability to walk and work. One can also conclude that BPI is presented as a multidimensional instrument for assessing chronic pain simple and easy to unders-tand, which can be applied to population-based studies, whether involving individuals of low socioeconomic status.
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